Concentration in the Greek private hospital sector: a descriptive analysis

Over the last 20 years, governments all around the world have attempted to boost the role of market and competition in health care industries in order to increase efficiency and reduce costs. The increased competition and the significant implications on costs and prices of health care services resulted in health care industries being transformed. Large firms are merging and acquiring other firms. If this trend continues, few firms will dominate the health care markets. In this study, I use the simple concentration ratio (CR) for the largest 4, 8 and 20 companies to measure the concentration of Greek private hospitals during the period 1997-2004. Also, the Gini coefficient for inequality is used. For the two different categories of hospitals used (a) general and neuropsychiatric and (b) obstetric/gynaecological it is evident that the top four firms of the first category accounted for 43% of sales in 1997, and 52% in 2004, while the four largest firms of the second category accounted for almost 83% in 1997, and 81% in 2004. Also, the Gini coefficient increases over the 8-year period examined from 0.69 in 1997 to 0.82 in 2004. It explains that the market of the private health care services becomes less equal in the sense that fewer private hospitals and clinics hold more and more of the share of the total sales. From a cross-industry analysis it is clear that the private hospital sector has the highest concentration rate. Finally, it appears that the market structure of the private hospitals in Greece resembles more closely to an oligopoly rather than a monopolistic competition, since very few firms dominate the market.     

Addressing government and market failures with payment incentives: Hospital reimbursement reform in Hainan, China

This paper examines the role of provider payment policy as an instrument for addressing government and market failures and controlling costs in the health sector, particularly in developing countries. We empirically evaluate the impact of provider payment reform in Hainan province, China, on expenditures for different categories of services that had been subject to distorted prices under fee-for-service. Using a pre-post study design with a control group, we analyze two years of claims data to assess the impact of a January 1997 change to prospective payment for a sub-sample of the hospitals. This difference-in-difference empirical strategy allows us to isolate the supply-side payment reform effects from demand-side policy interventions. We find that prepayment is associated with a slower increase in spending on expensive drugs and high technology services, compared to fee-for-service. The fact that payment reform is associated with reduced growth in spending on the most expensive drugs is particularly encouraging, given that drugs account for a remarkably high percentage of both the level and growth of aggregate health expenditure in China. Payment reform can be an effective policy instrument for correcting market failures and adverse side effects of government health sector interventions (such as distorted prices to assure access to basic services), both of which can lead to excessive health care expenditure growth. Such health spending growth can have a particularly high opportunity cost for developing countries.     

Insurer Market Structure and Variation in Commercial Health Care Spending

ObjectiveTo examine the relationship between insurance market structure and health care prices, utilization, and spending.MethodsRegression models are used to estimate the association between insurance market concentration and health care spending, utilization, and price, adjusting for differences in patient characteristics and other market-level traits.ResultsInsurance market concentration is inversely related to prices and spending, but positively related to utilization. Our results imply that, after adjusting for input price differences, a market with two equal size insurers is associated with 3.9 percent lower medical care spending per capita (p = .002) and 5.0 percent lower prices for health care services relative to one with three equal size insurers (p < .001).ConclusionGreater fragmentation in the insurance market might lead to higher prices and higher spending for care, suggesting some of the gains from insurer competition may be absorbed by higher prices for health care. Greater attention to prices and utilization in the provider market may need to accompany procompetitive insurance market strategies.     

A review of methods for controlling medical costs from the point of view of cost-effectiveness

Cost-effectiveness analysis is a method used to evaluate the outcomes and costs of treatments or interventions designed to improve health. It has been widely regarded as an important aid to providing health care services efficiently. This paper reviews several measures for controlling medical costs in Japan, where a fee-for-service system is employed to remunerate for medical services provision. From the point of view of cost-effectiveness, the first step in health care reform for controlling medical costs should be minimizing useless medical services because the cost-effectiveness ratio of these tends to infinity. For the purpose of minimizing unserviceable provision in the field of medicine, two approaches must be considered. One is establishing a system so that physicians can act as perfect agencies for their patients. The other is encouraging academic research on the effectiveness of medical services.     

我国卫生保健相对价格对人均卫生费用的影响研究：基于ARDL模型的分析

目的:深入研究卫生保健商品或服务的相对价格对人均卫生费用的短期与长期影响。方法:基于1986—2009年宏观时间序列数据,在考虑人均GDP、政府卫生投入等因素前提下,采用自回归分布滞后模型(ARDL)与误差修正模型(ECM)进行分析。结果与结论:⑴卫生保健商品相对价格对于人均实际卫生费用的影响要明显大于卫生保健服务相对价格和政府卫生投入比例增长率的影响;⑵相对于其他消费品,卫生保健商品相对价格的持续下降会促使人均实际卫生费用增长率也呈现下降趋势;卫生保健服务相对价格的下降可能会刺激人们卫生保健服务需求,提高实际人均卫生费用的增长率;⑶政府卫生投入比例的上升会导致实际人均卫生费用增长率增加,产生明显的正向效应。     

Physicians and health care: state, market or regulation? A false issue

A cost crisis in the health care sector has focused discussion on health care services and an assessment of the results of investments in the health sector, underlining the importance of medical doctors as key actors in this area. This article reviews the main analytical approaches to professionalism in the last decade and discusses the most recent paradigmatic shifts. New approaches have emerged for correlating the medical division of labor (contained in specialized fields which are becoming more and more fragmented) with structural and historical changes in the professional market, as well as the collective action developed by these interest groups in their relationship to the state. These approaches, more closely linked to political economy, have made important contributions to this debate, because they allow for a questioning of the kind of ideological polarization contained in health care reform proposals aimed at a withdrawal of the state and the rule of the market (with no analytical justification), in addition to shifting regulation to a position outside the historically mutable dynamics between the state, health care providers, and clients of the health care sector and the public policy arena.     

The regulation of general practice in the UK

When health professionals offer primary health services on a private market a number of problems can arise to do with choice, quality and supplier-induced demand. Professional self-regulation through qualification requirements and licensing procedures may offset some of the worst problems. However, in the UK, the primary health care sector is also subject to additional regulatory controls set within the context of the NHS. Private practitioners within the NHS function in a quasi-market setting, in which they are funded by public health authorities to provide services free at the point of delivery to their patients. Within this context there is regulation of quality, entry, prices and profits. This system can be contrasted with the much less extensive set of regulations applied to more market-based systems operating in countries such as the USA. Recent reforms in the UK have, however, initiated a movement towards a market-led system, extended the autonomy of health care practitioners, and increased the scope of financial incentives as a mechanism to promote professional quality and innovation. This article draws on the insights developed in Propper (1993) in her study of regulation and quasi-markets in secondary health care, education and community care. Its focus is on the extent of regulation in primary health care services; the effects of increased financial incentives on professional performance brought about by the NHS reforms; and, the scope for further deregulation of professional services in primary care.     

关于医院经营环境的分析

本文分析了医院经营环境几方面的变化情况:(1)政府对医院的补偿比例是下降趋势;(2)新的医疗保险制度即将启动;(3)医疗服务总体价格普遍提高;(4)医疗服务竞争市场迅速形成;(5)医疗服务成本费用迅速增长;(6)人口老龄化趋势,引起医疗服务需求数量、需求结构和需求模式的变化;(7)服务消费逐步向深层次发展;(8)企业职工基本医疗服务需求受到抑制。据此,提出相应对策。     

Organization of ambulatory care provision: a critical determinant of health system performance in developing countries

Success in the provision of ambulatory personal health services, i.e. providing individuals with treatment for acute illness and preventive health care on an ambulatory basis, is the most significant contributor to the health care system's performance in most developing countries. Ambulatory personal health care has the potential to contribute the largest immediate gains in health status in populations, especially for the poor. At present, such health care accounts for the largest share of the total health expenditure in most lower income countries. It frequently comprises the largest share of the financial burden on households associated with health care consumption, which is typically regressively distributed. The "organization" of ambulatory personal health services is a critical determinant of the health system's performance which, at present, is poorly understood and insufficiently considered in policies and programmes for reforming health care systems. This article begins with a brief analysis of the importance of ambulatory care in the overall health system performance and this is followed by a summary of the inadequate global data on ambulatory care organization. It then defines the concept of "macro organization of health care" at a system level. Outlined also is a framework for analysing the organization of health care services and the major pathways through which the organization of ambulatory personal health care services can affect system performance. Examples of recent policy interventions to influence primary care organization--both government and nongovernmental providers and market structure--are reviewed. It is argued that the characteristics of health care markets in developing countries and of most primary care goods result in relatively diverse and competitive environments for ambulatory care services, compared with other types of health care. Therefore, governments will be required to use a variety of approaches beyond direct public provision of services to improve performance. To do this wisely, much better information on ambulatory care organization is needed, as well as more experience with diverse approaches to improve performance.     

Controlling the US health care system with policy wedges

Two state-space models, one for the US health care system and one for the US economy, were developed and estimated for the period 1950-1999. The output from the US economy model was then used as a reference input to control the growth of the health care system model. The counterfactual history produced by simulating the controlled model shows that a reduction in investment and volume-based services would have been needed to bring the growth of the health care system in line with the US economy. Specifically, a 13% reduction in capital expenditure, a 15% reduction in drug prices and a 32% reduction in prices for physician's services would have been needed over the late twentieth century. The methodology also suggests how universal health care programs might be designed using planning and economic incentives without either over-engineering plan provisions or using centralized, command-and-control approaches.     

美国营利和非营利医院的评价

美国营利和非营利医院的经营目的的不同，但在管理方法和市场竞争策略上正在逐步趋同。它们相互竞争，在医疗服务的价格上各有高低，总体上是有竞争的医院医疗服务的价格要高于没有竞争的医院。在扣除了税收、公共的补贴及慈善损助等之后进行的分析发现，营利医院和非营利医院的医疗服务成本各有高低，但营利医院的医疗服务的效率相对较 。两种类型的医院医疗服务的质量总体上没有差别。非营利医院提供了较多的社会医疗服务。     

The many different prices paid to providers and the flawed theory of cost shifting: is it time for a more rational all-payer system?

In developed nations that rely on multiple, competing health insurers-for example, Switzerland and Germany-the prices for health care services and products are subject to uniform price schedules that are either set by government or negotiated on a regional basis between associations of health insurers and associations of providers of health care. In the United States, some states-notably Maryland-have used such all-payer systems for hospitals only. Elsewhere in the United States, prices are negotiated between individual payers and providers. This situation has resulted in an opaque system in which payers with market power force weaker payers to cover disproportionate shares of providers' fixed costs-a phenomenon sometimes termed cost shifting-or providers simply succeed in charging higher prices when they can. In this article I propose that this price-discriminatory system be replaced over time by an all-payer system as a means to better control costs and ensure equitable payment.     

It's the prices,stupid: why the United States is so different from other countries

This paper uses the latest data from the Organization for Economic Cooperation and Development (OECD) to compare the health systems of the thirty member countries in 2000. Total health spending--the distribution of public and private health spending in the OECD countries--is presented and discussed. U.S. public spending as a percentage of GDP (5.8 percent) is virtually identical to public spending in the United Kingdom, Italy, and Japan (5.9 percent each) and not much smaller than in Canada (6.5 percent). The paper also compares pharmaceutical spending, health system capacity, and use of medical services. The data show that the United States spends more on health care than any other country. However, on most measures of health services use, the United States is below the OECD median. These facts suggest that the difference in spending is caused mostly by higher prices for health care goods and services in the United States.     

Coinsurance effects on dental prices

For many Americans the cost of dental services represents a barrier to receiving regular dental care and maintaining proper oral health. The recent growth of the dental insurance industry, however, may partly offset this price barrier among insureds. Our purpose is to examine the relationship between coinsurance and dental prices for 16 dental services among a sample of Pennsylvania Blue Shield (PBS) adult insureds. The dependent price measure is the annual average gross price paid for 16 specific preventive, restorative, periodontic, endodontic, prosthodontic, and surgical dental services. Independent variables in the price model include the insured's age, education, coinsurance rates, time costs, market area, non-wage income, oral health status, area dentist-population ratio and usual source of care. Data sources are 1980 PBS claims and coinsurance rate data and a mail survey of sampled insureds. OLS regression analysis reveals that the model's independent variables explain little dental price variation. No variable is consistently significant across services, but market area, coinsurance rates, and time costs alternately dominate across equations. These results suggest that, among adult insureds, coinsurance and time costs influence dental fees in a minority of dental services. Insurance reduces the patient's sensitivity to money price, and non-price factors correspondingly seem to become more important in patient search.     

Running on empty: health care energy use in a developing country

Health care systems require reliable energy for high-quality services. Rising fossil fuel prices globally limit the capacity of developing countries to provide continuous and essential health care services. Global health care projects should focus on energy innovation for health care use.     

Parity for mental health and substance abuse care under managed care

BACKGROUND: Parity in insurance coverage for mental health and substance abuse has been a key goal of mental health and substance abuse care advocates in the United States during most of the past 20 years. The push for parity began during the era of indemnity insurance and fee for service payment when benefit design was the main rationing device in health care. The central economic argument for enacting legislation aimed at regulating the insurance benefit was to address market failure stemming from adverse selection. The case against parity was based on inefficiency related to moral hazard. Empirical analyses provided evidence that ambulatory mental health services were considerably more responsive to the terms of insurance than were ambulatory medical services. AIMS: Our goal in this research is to reexamine the economics of parity in the light of recent changes in the delivery of health care in the United States. Specifically managed care has fundamentally altered the way in which health services are rationed. Benefit design is now only one mechanism among many that are used to allocate health care resources and control costs. We examine the implication of these changes for policies aimed at achieving parity in insurance coverage. METHOD: We develop a theoretical approach to characterizing rationing under managed care. We then analyze the traditional efficiency concerns in insurance, adverse selection and moral hazard in the context of policy aimed at regulating health and mental health benefits under private insurance. RESULTS: We show that since managed care controls costs and utilization in new ways parity in benefit design no longer implies equal access to and quality of mental health and substance abuse care. Because costs are controlled by management under managed care and not primarily by out of pocket prices paid by consumers, demand response recedes as an efficiency argument against parity. At the same time parity in benefit design may accomplish less with respect to providing a remedy to problems related to adverse selection.     

社会资本投资于医疗服务领域的相关政策

目前,我国开放医疗服务市场,鼓励社会资本投资于卫生领域,需要明确几个重要的相关政策:打破行政垄断,放宽市场准入;平衡卫生服务的规划指导与市场竞争的关系;在市场开放的同时,必须保证基本医疗服务需求;明确社会资本投资与卫生的重点和途径;完善分类管理政策和公立医院向民办营利性医院和非营利性医院转制的政策;鼓励公立医院的管理体制和治理结构创新;加强对医疗服务市场的监管,克服市场失灵.     

略论经济转型期医德的困惑及其转变

社会关系的深刻变化,使医德的理论与实践面临着困惑。医疗行为理念上的泛道德化倾向和事实上的非道德主义观念,是导致医德实践进退维谷的社会心理根源。为此,必须正视医务人员理的利益需求,构建符合市场原则的实用医德体系,正确对待“德”与“利”的关系,使医德所肯定的价值观与医疗行为的社会价值相统一,并与医务人员的劳动价值相一致,变“应然的医德”为“实然的医德”。     

Regulating India's health services: To what end? What future?

India has a comprehensive legal and regulatory framework and large public health delivery system which are disconnected from the realities of health care delivery and financing for most Indians. In reviewing the current bureaucratic approach to regulation, we find an extensive set of rules and procedures, though we argue it has failed in three critical ways, namely to (1) protect the interests of vulnerable groups; (2) demonstrate how health financing meets the public interests; (3) generate the trust of providers and the public. The paper reviews the state of alternative approaches to regulation of health services in India, using consumer and market based approaches, as well as multi-actor and collaborative approaches. We argue that poor regulation is a symptom of poor governance and that simply creating and enforcing the rules will continue to have limited effects. Rather than advocate for better implementation and expansion of the current bureaucratic approach, where Ministries of Health focus on their roles as inspectorate and provider, we propose that India's future health system is more likely to achieve its goals through greater attention to consumer and other market oriented approaches, and through collaborative mechanisms that enhance accountability. Civil society organizations, the media, and provider organizations can play more active parts in disclosing and using information on the use of health resources and the performance of public and private providers. The overview of the health sector would be more effective, if Indian Ministries of Health were to actively facilitate participation of these key stakeholders and the use of information.